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Lyon E, Goldman J, Lee B, Campbell M, Selvarangan R, Monsees E. Repeat tracheal aspirate cultures in pediatric intensive care patients: Frequency, resistance, and antimicrobial use. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38818881 DOI: 10.1017/ice.2024.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To evaluate the clinical impact and features associated with repeat tracheal aspirate (TA) cultures in children admitted to the intensive care unit. DESIGN Retrospective cohort study. SETTING A 338-bed freestanding, tertiary pediatric academic medical center with pediatric medical intensive care unit (PICU) and cardiac intensive care units (CICU). PATIENTS Children ≤18 years of age who were admitted to either the PICU or CICU who had ≥2 TA cultures in a single intensive care admission. METHODS Patients with ≥2 TA cultures between 2018 and 2019 were included in this study. The following information was collected: patient demographics, clinical data summarizing patient condition at the time of culture collection, number of TA cultures per patient, antibiotic usage, and microbiologic data. Descriptive statistics established the frequency of TA collection, time between culturing, clinical reasoning for collection, antibiotic exposure, and development of multidrug-resistant organisms (MDRO). RESULTS Sixty-three patients had repeat TA cultures and accounted for 252 TA cultures during the study period. Most patients with repeat TA cultures were admitted to the PICU (71%) and were male (65%). A median of 3 TA cultures per patient were obtained with 50% of repeat cultures occurring within 7 days from the previous culture. Sixty-six percent of patients had the same organism cultured on ≥2 TA cultures. Most antibiotics were not modified or continued to treat the results of the TA culture. CONCLUSIONS Repeat TA cultures frequently show the same pathogens, and results do not often influence antibiotic selection or usage. Repeat TA cultures did demonstrate the development of MDROs.
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Affiliation(s)
- Edward Lyon
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jennifer Goldman
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, University of Missouri, Kansas City, MO, USA
| | - Brian Lee
- School of Medicine, University of Missouri, Kansas City, MO, USA
- Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO, USA
| | - Margaret Campbell
- Department of Graduate Medical Education, Children's Mercy Hospital, Kansas City, MO, USA
| | - Rangaraj Selvarangan
- School of Medicine, University of Missouri, Kansas City, MO, USA
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, MO, USA
| | - Elizabeth Monsees
- School of Medicine, University of Missouri, Kansas City, MO, USA
- Department of Service and Performance Excellence, Children's Mercy Hospital, Kansas City, MO, USA
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2
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Becerra-Hervás J, Guitart C, Covas A, Bobillo-Pérez S, Rodríguez-Fanjul J, Carrasco-Jordan JL, Cambra Lasaosa FJ, Jordan I, Balaguer M. The Clinical Pulmonary Infection Score Combined with Procalcitonin and Lung Ultrasound (CPIS-PLUS), a Good Tool for Ventilator Associated Pneumonia Early Diagnosis in Pediatrics. CHILDREN (BASEL, SWITZERLAND) 2024; 11:592. [PMID: 38790587 PMCID: PMC11120099 DOI: 10.3390/children11050592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/26/2024]
Abstract
Ventilator-associated pneumonia (VAP) is common in Pediatric Intensive Care Units. Although early detection is crucial, current diagnostic methods are not definitive. This study aimed to identify lung ultrasound (LUS) findings and procalcitonin (PCT) values in pediatric patients with VAP to create a new early diagnosis score combined with the Clinical Pulmonary Infection Score (CPIS), the CPIS-PLUS score. Prospective longitudinal and interventional study. Pediatric patients with suspected VAP were included and classified into VAP or non-VAP groups, based on Centers of Disease Control (CDC) criteria for the final diagnosis. A chest-X-ray (CXR), LUS, and blood test were performed within the first 12 h of admission. CPIS score was calculated. A total of 108 patients with VAP suspicion were included, and VAP was finally diagnosed in 51 (47%) patients. CPIS-PLUS showed high accuracy in VAP diagnosis with a sensitivity (Sn) of 80% (95% CI 65-89%) and specificity (Sp) of 73% (95% CI 54-86%). The area under the curve (AUC) resulted in 0.86 for CPIS-PLUS vs. 0.61 for CPIS. In conclusion, this pilot study showed that CPIS-PLUS could be a potential and reliable tool for VAP early diagnosis in pediatric patients. Internal and external validations are needed to confirm the potential value of this score to facilitate VAP diagnosis in pediatric patients.
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Affiliation(s)
- Judit Becerra-Hervás
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Faculty of Medicine, University of Barcelona, c. Casanova, 143, 08036 Barcelona, Spain;
| | - Carmina Guitart
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
| | - Aina Covas
- Neonatal Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain;
| | - Sara Bobillo-Pérez
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit, Department of Paediatrics, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, 08916 Badalona, Spain;
| | - Josep L. Carrasco-Jordan
- Faculty of Medicine, University of Barcelona, c. Casanova, 143, 08036 Barcelona, Spain;
- Biostatistics, Department of Basic Clinical Practice, University of Barcelona, 08036 Barcelona, Spain
| | - Francisco José Cambra Lasaosa
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Faculty of Medicine, University of Barcelona, c. Casanova, 143, 08036 Barcelona, Spain;
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
- Pediatric Infectious Diseases Research Group, Institut de Recerca Sant Joan de Déu, CIBERESP, 08950 Barcelona, Spain
| | - Mònica Balaguer
- Pediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Passeig de Sant Joan de Déu, 2, 08950 Barcelona, Spain; (J.B.-H.); (C.G.); (S.B.-P.); (F.J.C.L.); (M.B.)
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, 08950 Barcelona, Spain
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3
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Clark JA, Conway Morris A, Kanaris C, Inwald D, Butt W, Osowicki J, Schlapbach LJ, Curran MD, White D, Daubney E, Agrawal S, Navapurkar V, Török ME, Baker S, Pathan N. A qualitative investigation of paediatric intensive care staff attitudes towards the diagnosis of lower respiratory tract infection in the molecular diagnostics era. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2023; 1:10. [PMID: 37425493 PMCID: PMC10329081 DOI: 10.1007/s44253-023-00008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023]
Abstract
Background In the past decade, molecular diagnostic syndromic arrays incorporating a range of bacterial and viral pathogens have been described. It is unclear how paediatric intensive care unit (PICU) staff diagnose lower respiratory tract infection (LRTI) and integrate diagnostic array results into antimicrobial decision-making. Methods An online survey with eleven questions was distributed throughout paediatric intensive care societies in the UK, continental Europe and Australasia with a total of 755 members. Participants were asked to rate the clinical factors and investigations they used when prescribing for LRTI. Semi-structured interviews were undertaken with staff who participated in a single-centre observational study of a 52-pathogen diagnostic array. Results Seventy-two survey responses were received; most responses were from senior doctors. Whilst diagnostic arrays were used less frequently than routine investigations (i.e. microbiological culture), they were of comparable perceived utility when making antimicrobial decisions. Prescribers reported that for arrays to be clinically impactful, they would need to deliver results within 6 h for stable patients and within 1 h for unstable patients to inform their immediate decision to prescribe antimicrobials. From 16 staff interviews, we identified that arrays were helpful for the diagnosis and screening of bacterial LRTI. Staff reported it could be challenging to interpret results in some cases due to the high sensitivity of the test. Therefore, results were considered within the context of the patient and discussed within the multidisciplinary team. Conclusions Diagnostic arrays were considered of comparable value to microbiological investigations by PICU prescribers. Our findings support the need for further clinical and economic evaluation of diagnostic arrays in a randomised control trial. Trial registration Clinicaltrials.gov, NCT04233268. Registered on 18 January 2020. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-023-00008-z.
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Affiliation(s)
- John A. Clark
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Conway Morris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Constantinos Kanaris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Warwick Butt
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital Melbourne, Parkville, Australia
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology and Children’s Research Center, University Children’s Hospital Zürich, Zurich, Switzerland
| | - Martin D. Curran
- United Kingdom Health Security Agency, Clinical Microbiology and Public Health Laboratory, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vilas Navapurkar
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M. Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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4
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Sdougka M, Simitsopoulou M, Volakli E, Violaki A, Georgopoulou V, Ftergioti A, Roilides E, Iosifidis E. Evaluation of Five Host Inflammatory Biomarkers in Early Diagnosis of Ventilator-Associated Pneumonia in Critically Ill Children: A Prospective Single Center Cohort Study. Antibiotics (Basel) 2023; 12:antibiotics12050921. [PMID: 37237823 DOI: 10.3390/antibiotics12050921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/05/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
Background: Early diagnosis of ventilator-associated pneumonia (VAP) remains a challenge due to subjective clinical criteria and the low discriminative power of diagnostic tests. We assessed whether rapid molecular diagnostics in combination with Clinically Pulmonary Index Score (CPIS) scoring, microbiological surveillance and biomarker measurements of PTX-3, SP-D, s-TREM, PTX-3, IL-1β and IL-8 in the blood or lung could improve the accuracy of VAP diagnosis and follow-up in critically ill children. Methods: A prospective pragmatic study in a Pediatric Intensive Care Unit (PICU) was conducted on ventilated critically ill children divided into two groups: high and low suspicion of VAP according to modified Clinically Pulmonary Index Score (mCPIS). Blood and bronchial samples were collected on days 1, 3, 6 and 12 after event onset. Rapid diagnostics were used for pathogen identification and ELISA for PTX-3, SP-D, s-TREM, IL-1β and IL-8 measurements. Results: Among 20 enrolled patients, 12 had a high suspicion (mCPIS > 6), and 8 had a low suspicion of VAP (mCPIS < 6); 65% were male; and 35% had chronic disease. IL-1β levels at day 1 correlated significantly with the number of mechanical ventilation days (rs = 0.67, p < 0.001) and the PICU stay (r = 0.66; p < 0.002). No significant differences were found in the levels of the other biomarkers between the two groups. Mortality was recorded in two patients with high VAP suspicion. Conclusions: PTX-3, SP-D, s-TREM, IL-1β and IL-8 biomarkers could not discriminate patients with a high or low suspicion of VAP diagnosis.
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Affiliation(s)
- Maria Sdougka
- Pediatric Intensive Care Unit, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Maria Simitsopoulou
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Elena Volakli
- Pediatric Intensive Care Unit, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Asimina Violaki
- Pediatric Intensive Care Unit, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Vivian Georgopoulou
- Medical Imaging Department, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Argiro Ftergioti
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration General Hospital, 54942 Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Disease Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Hippokration General Hospital, 54942 Thessaloniki, Greece
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5
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Clark J, White D, Daubney E, Curran M, Bousfield R, Gouliouris T, Powell E, Palmer A, Agrawal S, Inwald D, Kean I, Török ME, Baker S, Pathan N. Low diagnostic yield and time to diagnostic confirmation results in prolonged use of antimicrobials in critically ill children. Wellcome Open Res 2022; 6:119. [PMID: 35299710 PMCID: PMC8902261.2 DOI: 10.12688/wellcomeopenres.16848.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Broad-spectrum antimicrobial therapy is a key driver of antimicrobial resistance. Here, we aimed to review indications for antimicrobial therapy, determine the proportion of suspected bacterial infections that are confirmed by culture, and assess the time taken for microbiology test results to become available in the paediatric intensive care unit (PICU). Methods: A single-centre prospective observational cohort study of 100 consecutive general PICU admissions from 30 October 2019 to 19 February 2020. Data were collected from the hospital medical record and entered into a study database prior to statistical analysis using standard methods. Results: Of all episodes of suspected infection, 22% of lower respiratory tract infection, 43% of bloodstream and 0% of central nervous system infection were associated with growth on microbiology culture. 90% of children received antimicrobial therapy. Hospital-acquired infection occurred less commonly than primary infection, but an organism was grown in a greater proportion (64%) of cultures. Final laboratory reports for negative cultures were issued at a median of 120.3 hours for blood cultures and 55.5 hours for endotracheal tube aspirate cultures. Conclusions: Despite most critically children receiving antimicrobial therapy, infection was often not microbiologically confirmed. Novel molecular diagnostics may improve rationalisation of treatment in this population.
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Affiliation(s)
- John Clark
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Martin Curran
- Clinical Microbiology and Public Health Laboratory, Public Health England, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Rachel Bousfield
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Theodore Gouliouris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Elizabeth Powell
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Adam Palmer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Shruti Agrawal
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Iain Kean
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - M Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
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6
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Clark JA, Kean IRL, Curran MD, Khokhar F, White D, Daubney E, Conway Morris A, Navapurkar V, Bartholdson Scott J, Maes M, Bousfield R, Gouliouris T, Agrawal S, Inwald D, Zhang Z, Török ME, Baker S, Pathan N. Rapid Assay for Sick Children with Acute Lung infection Study (RASCALS): diagnostic cohort study protocol. BMJ Open 2021; 11:e056197. [PMID: 34845080 PMCID: PMC8634010 DOI: 10.1136/bmjopen-2021-056197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/11/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Lower respiratory tract infection (LRTI) is the most commonly treated infection in critically ill children. Pathogens are infrequently identified on routine respiratory culture, and this is a time-consuming process. A syndromic approach to rapid molecular testing that includes a wide range of bacterial and fungal targets has the potential to aid clinical decision making and reduce unnecessary broad spectrum antimicrobial prescribing. Here, we describe a single-centre prospective cohort study investigating the use of a 52-pathogen TaqMan array card (TAC) for LRTI in the paediatric intensive care unit (PICU). METHODS AND ANALYSIS Critically ill children with suspected LRTI will be enrolled to this 100 patient single-centre prospective observational study in a PICU in the East of England. Samples will be obtained via routine non-bronchoscopic bronchoalveolar lavage which will be sent for standard microbiology culture in addition to TAC. A blood draw will be obtained via any existing vascular access device. The primary outcomes of the study will be (1) concordance of TAC result with routine culture and 16S rRNA gene sequencing and (2) time of diagnostic result from TAC versus routine culture. Secondary outcomes will include impact of the test on total antimicrobial prescriptions, a description of the inflammatory profile of the lung and blood in response to pneumonia and a description of the clinical experience of medical and nursing staff using TAC. ETHICS AND DISSEMINATION This study has been approved by the Yorkshire and the Humber-Bradford Leeds Research Ethics Committee (REC reference 20/YH/0089). Informed consent will be obtained from all participants. Results will be published in peer-reviewed publications and international conferences. TRIAL REGISTRATION NUMBER NCT04233268.
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Affiliation(s)
- John Alexander Clark
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge, UK
| | - Fahad Khokhar
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Vilas Navapurkar
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Rachel Bousfield
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Shruti Agrawal
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zhenguang Zhang
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - M Estée Török
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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7
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Clark J, White D, Daubney E, Curran M, Bousfield R, Gouliouris T, Powell E, Palmer A, Agrawal S, Inwald D, Kean I, Török ME, Baker S, Pathan N. Low diagnostic yield and time to diagnostic confirmation results in prolonged use of antimicrobials in critically ill children. Wellcome Open Res 2021; 6:119. [PMID: 35299710 PMCID: PMC8902261 DOI: 10.12688/wellcomeopenres.16848.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Broad-spectrum antimicrobial therapy is a key driver of antimicrobial resistance. Here, we aimed to review indications for antimicrobial therapy, determine the proportion of suspected bacterial infections that are confirmed by culture, and assess the time taken for microbiology test results to become available in the paediatric intensive care unit (PICU). Methods: A single-centre prospective observational cohort study of 100 consecutive general PICU admissions from 30 October 2019 to 19 February 2020. Data were collected from the hospital medical record and entered into a study database prior to statistical analysis using standard methods. Results: Of all episodes of suspected infection, 22% of lower respiratory tract infection, 43% of bloodstream and 0% of central nervous system infection were associated with growth on microbiology culture. 90% of children received antimicrobial therapy. Hospital-acquired infection occurred less commonly than primary infection, but an organism was grown in a greater proportion (64%) of cultures. Final laboratory reports for negative cultures were issued at a median of 120.3 hours for blood cultures and 55.5 hours for endotracheal tube aspirate cultures. Conclusions: Despite most critically children receiving antimicrobial therapy, infection was often not microbiologically confirmed. Novel molecular diagnostics may improve rationalisation of treatment in this population.
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Affiliation(s)
- John Clark
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Martin Curran
- Clinical Microbiology and Public Health Laboratory, Public Health England, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Rachel Bousfield
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Theodore Gouliouris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Elizabeth Powell
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Adam Palmer
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Shruti Agrawal
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Iain Kean
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - M. Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Cambridge, Cambridgeshire, CB2 0QQ, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 0QQ, UK
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8
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Pediatric Ventilator-Associated Events: Analysis of the Pediatric Ventilator-Associated Infection Data. Pediatr Crit Care Med 2018; 19:e631-e636. [PMID: 30234739 DOI: 10.1097/pcc.0000000000001723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To compare the prevalence of infection applying the proposed pediatric ventilator-associated events criteria versus clinician-diagnosed ventilator-associated infection to subjects in the pediatric ventilator-associated infection study. DESIGN Analysis of prospectively collected data from the pediatric ventilator-associated infection study. SETTING PICUs of 47 hospitals in the United States, Canada, and Australia. PATIENTS Two-hundred twenty-nine children ventilated for greater than 48 hours who had respiratory secretion cultures performed to evaluate for suspected ventilator-associated infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Applying the proposed pediatric ventilator-associated event criteria, 15 of 229 subjects in the ventilator-associated infection study qualified as "ventilator-associated condition" and five of 229 (2%) met criteria for "infection-related ventilator-associated complication." This was compared with 89 of 229 (39%) diagnosed as clinical ventilator-associated infection (Kappa = 0.068). Ten of 15 subjects identified as ventilator-associated condition did not meet criteria for infection-related ventilator-associated complication primarily because they did not receive 4 days of antibiotics. Ventilator-associated condition subjects were similar demographically to nonventilator-associated condition subjects and had similar mortality (13% vs 10%), PICU-free days (6.9 ± 7.7; interquartile range, 0-14 vs 9.8 ± 9.6; interquartile range, 0-19; p = 0.25), but fewer ventilator-free days (6.6 ± 9.3; interquartile range, 1-15 vs 12.4 ± 10.7; interquartile range, 0-22; p = 0.04). The clinical ventilator-associated infection diagnosis in the ventilator-associated infection study was associated with fewer PICU-free days but no difference in mortality or ventilator-free days. CONCLUSIONS The ventilator-associated event criteria appear to be insensitive to the clinical diagnosis of ventilator-associated infection. Differentiation between ventilator-associated condition and infection-related ventilator-associated complication was primarily determined by the clinician decision to treat with antibiotics rather than clinical signs and symptoms. The utility of the proposed pediatric ventilator-associated event criteria as a surrogate for ventilator-associated infection criteria is unclear.
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Iosifidis E, Pitsava G, Roilides E. Ventilator-associated pneumonia in neonates and children: a systematic analysis of diagnostic methods and prevention. Future Microbiol 2018; 13:1431-1446. [PMID: 30256161 DOI: 10.2217/fmb-2018-0108] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AIM While ventilator-associated pneumonia (VAP) remains frequent in Pediatric ICU, there is no gold standard for diagnosis. METHODOLOGY We conducted a systematic PUBMED analysis (January 1990-January 2017) searching original, full-length studies addressing only pediatric patients; for VAP diagnosis, only those comparing different diagnostic methods and for VAP prevention those implementing preventive measures. RESULTS Among 367 articles, 17 and 16 were analyzed for diagnosis and prevention, respectively. For diagnosis, 13 studies used CDC criteria; whereas, 14 assessed algorithms: clinical pulmonary index score, ventilator-associated events and biomarkers. Among five randomized trials assessing preventive strategies one found a role of probiotics. Ventilator-care bundles reduced VAP rates. CONCLUSION Absence of diagnostic gold standard impedes comparison of current approaches and preventive strategies.
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Affiliation(s)
- Elias Iosifidis
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki Greece
| | - Georgia Pitsava
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki Greece
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki Greece
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Abo-Hagar HH, Abo-Elezz AAE, Mehrez M, Mabrouk MM, Elshora OA. Diagnostic Efficacy of Serum Amyloid A Protein and Soluble Intercellular Adhesion Molecule 1 in Pediatric Ventilator-Associated Pneumonia. J Intensive Care Med 2017; 34:503-510. [DOI: 10.1177/0885066617702598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives: Study of inflammatory biomarkers which may aid in early detection of ventilator-associated pneumonia (VAP) in children and predicting their outcome. Patients: Thirty-five children, aged 2 months to 13 years, needed mechanical ventilation (MV) for more than 48 hours due to causes other than pneumonia. Methods: Measurement of serum amyloid A (SAA) protein, soluble intercellular adhesion molecule 1 (sICAM-1), and C-reactive protein (CRP), modified clinical pulmonary infection score (CPIS) and performing culture of endotracheal aspirate at the start and on the third day of MV. Results: Ventilator-associated pneumonia was diagnosed by CPIS in 6 (17.1%) of 35 patients. On the third day of MV, there was a significant increase in serum mean levels of SAA, sICAM-1, and CRP in comparison to the start of MV ( P = .005, .004, and .01, respectively). Three (50%) of 6 patients with VAP died, while 4 (14.28%) of 28 patients without VAP died. The sensitivity of serum SAA, sICAM-1, and CPIS were 100% for predicting VAP, while specificity was highest for CPIS (96.55%) followed by SAA (93.1%). Combination of CPIS and SAA increased the specificity to 100%. For predicting nonsurvival, serum SAA and sICAM-1 had a sensitivity of 100% and a specificity of 92.86% and 89.29%, respectively. Conclusion: Serum amyloid A and sICAM-1 may be considered as reliable markers for detection of VAP. Combination of serum SAA with CPIS increased the specificity to 100%. Measurement of SAA in patients with VAP also had a good predictive value for nonsurvival in such patients.
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Affiliation(s)
- Hamdy H. Abo-Hagar
- Pediatric Intensive Care Unit, Faculty of Medicine, Pediatric Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Ahmed Abd ElBasset Abo-Elezz
- Pediatric Intensive Care Unit, Faculty of Medicine, Pediatric Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Mostafa Mehrez
- Pediatric Intensive Care Unit, Faculty of Medicine, Pediatric Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Maaly M. Mabrouk
- Clinical Pathology Department, Tanta University, Gharbia Governorate, Tanta, Egypt
| | - Ola A. Elshora
- Clinical Pathology Department, Tanta University, Gharbia Governorate, Tanta, Egypt
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İşgüder R, Ceylan G, Ağın H, Gülfidan G, Ayhan Y, Devrim İ. New parameters for childhood ventilator associated pneumonia diagnosis. Pediatr Pulmonol 2017; 52:119-128. [PMID: 27280471 DOI: 10.1002/ppul.23504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/18/2016] [Accepted: 05/26/2016] [Indexed: 11/12/2022]
Abstract
PURPOSE Our aim is to determine whether the presence of soluble triggering receptor expressed on myeloid cells-1 (s-TREM-1) of bronchoalveolar lavage fluid (BALF), serum procalcitonin levels (PCT), and Clinical Pulmonary Infection Score (CPIS) have diagnostic value in children with VAP. METHODS All children followed in pediatric intensive care unit (PICU) who were mechanically ventilated at least for 48 hr between January 2014 and December 2015 were enrolled into our study. BALF sample was obtained via non-bronchoscopic method from the children with VAP suspicion (case group) and s-TREM-1 levels were measured. Furthermore we calculated CPIS and measured serum PCT levels. Same procedures were applied to the control group who were admitted to PICU without infectious problems and who were not under antimicrobial therapy. First we compared the case group with the control group and then we compared the quantitative culture confirmed and non-confirmed VAP cases among themselves. RESULTS Case group (n:58) had significant higher PCT and s-TREM-1 levels compared to control group (n:58). The VAP confirmed cases had higher s-TREM-1, PCT ve CPIS levels compared to non-confirmed VAP cases. s-TREM-1, PCT ve CPIS variables were found to be independent risk factors for VAP. The cutoff values for s-TREM-1, CPIS, and PCT, are 281 pg/ml, 6, and 1.9 ng/ml, respectively. The patients whose s-TREM-1, CPIS, and PCT values above the cutoff levels were found to have higher cumulative VAP rate. CONCLUSIONS s-TREM-1 of BALF, serum PCT levels, and CPIS are useful predictors for ventilator-associated pneumonia diagnosis in children. Pediatr Pulmonol. 2017;52:119-128. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rana İşgüder
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Research and Training Hospital, Izmir, Turkey
| | - Gökhan Ceylan
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Research and Training Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children's Research and Training Hospital, Izmir, Turkey
| | - Gamze Gülfidan
- Department of Microbiology, Dr. Behçet Uz Children's Research and Training Hospital, Izmir, Turkey
| | - Yüce Ayhan
- Department of Microbiology, Dr. Behçet Uz Children's Research and Training Hospital, Izmir, Turkey
| | - İlker Devrim
- Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Research and Training Hospital, Izmir, Turkey
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Nobahar M, Razavi MR, Malek F, Ghorbani R. Effects of hydrogen peroxide mouthwash on preventing ventilator-associated pneumonia in patients admitted to the intensive care unit. Braz J Infect Dis 2016; 20:444-50. [PMID: 27471125 PMCID: PMC9425535 DOI: 10.1016/j.bjid.2016.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/23/2016] [Accepted: 06/27/2016] [Indexed: 02/05/2023] Open
Abstract
AIMS The aim of the study was to determine the effect of hydrogen peroxide (HP) mouthwash on the incidence of ventilator associated pneumonia (VAP) in patients admitted to the intensive care unit (ICU). METHODS This was a randomized clinical trial conducted on 68 patients. The intervention group used 3% HP as mouthwash and the control group used mouthwashes with 0.9% normal saline (NS) twice a day. Data were collected using a questionnaire and the Modified Clinical Pulmonary Infection Score (MCPIS). MCPIS includes five items, body temperature: white blood cell count, pulmonary secretions, the ratio of pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2), and the chest X-ray. Each of these items scored 0-2. Scores ≥6 were considered as VAP signs. The SPSS-20 software was employed to analyze the data. RESULTS In total, 14.7% patients of the HP group and 38.2% patients of the NS group contracted VAP. The risk of VAP in the NS group was 2.60 times greater than that in the HP group (RR=2.60, 95% CI: 1.04-6.49, p=0.0279). The mean±SD MCPIS was calculated as 3.91±1.35 in the HP group and 4.65±1.55 in the NS group, a difference statistically significant (p=0.042). There were no significant differences in the risk factors for VAP between the two groups. CONCLUSION HP mouthwash was found more effective than NS in reducing VAP. HP mouthwash can therefore be used in routine nursing care for reducing VAP.
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Affiliation(s)
- Monir Nobahar
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran; Department of Nursing, Faculty of Nursing and Allied Health, Semnan University of Medical Sciences, Semnan, Iran.
| | - Mohammad Reza Razavi
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Farhad Malek
- Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Raheb Ghorbani
- Research Center for Social Determinants of Health and Research Center of Physiology, Department of Community Medicine, Faculty of Medicine, Semnan University of Medical Sciences, Semnan, Iran
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Aelami MH, Lotfi M, Zingg W. Ventilator-associated pneumonia in neonates, infants and children. Antimicrob Resist Infect Control 2014. [DOI: 10.1186/2047-2994-3-30] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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